Provider Demographics
NPI:1558552844
Name:BOFILL, MARTHA (PSYD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BOFILL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1348
Mailing Address - Country:US
Mailing Address - Phone:786-587-2617
Mailing Address - Fax:
Practice Address - Street 1:9801 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1348
Practice Address - Country:US
Practice Address - Phone:786-587-2617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7089103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY7089OtherSTATE LICENSE